Britt Schloemer APRN 2018 KY NAPNAP Annual Update Objectives Describe what a migraine is Present an update on acute migraine treatment recommendations Discuss treatment options for migraine prevention ID: 918785
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Slide1
Migraine Essentials in Primary Care
Britt Schloemer, APRN
2018 KY NAPNAP Annual Update
Slide2Objectives
Describe what a migraine is
Present an update on acute migraine treatment recommendations
Discuss treatment options for migraine prevention
Discuss treatment and management priorities when caring for a child with migraines
Present resources that can be utilized by both patients and PCPs when treating and managing migraines
Slide3Migraine
What is a migraine?
Slide4International Headache Society (IHS) Diagnostic Criteria
(Patients < 15 years of age)
Migraine without aura:
Migraine with aura:
At least 5 attacks
Duration 4-72 hours
At least
2
of the following:
Unilateral
Pulsating quality
Moderate to severe intensity
Exacerbation by activity
At least
one
of the following:
Nausea, vomiting, or both
Photophobia or
phonophobia
At least 2 attacks
At least
3
of the following:
At least one fully reversible aura symptoms indicating focal, cerebral, cortical or brainstem dysfunction
At least one aura symptoms developing gradually for 4 minutes or ≥ 2 symptoms in succession
No aura > 60 minutes
Headache begins before, simultaneously, or within 60 minutes of aura
Migraine Statistics
(Alfonzo & Chen, 2015)
Listed among the top 5 youth health problems
3
rd
most common referral to the ED
The most common cause of headache (HA) in children
Incidence and prevalence increases with age:3 – 7 years: 2%
7 - 11 years: 7%
11 – 15 years: 20%
Prepubertal
males: females – 3:2
Adolescent females: postpubescent males – 3:1
Slide6What do parents do?
Slide7What do they think is happening?
Slide8But, what if…
Lee, 2017
Slide9Red flags could indicate:
Increase in intracranial pressure
Focal irritation
Stroke
Infection
Red flag may indicate an emergency:
Refer to ED
Head CT
Slide10Rare migraine variants
Can act like strokes
Hemiplegic migraine
Basilar artery migraine
Opthalmoplegic
migraine
Alice in Wonderland Syndrome
Confusional migraineMay not be associated with headache
Cyclic vomiting
Abdominal migraine
Benign paroxysmal vertigo
Benign paroxysmal torticollis
Slide11Slide12Lets talk imaging
U.S. Headache Consortium Guidelines for
Neuroimaging
in Patients Presenting With Headaches
Imaging is recommended:
In patients with non-acute headache and unexplained findings on neurologic examination
In patients with neurologic symptoms (headache that is worsened with use of Valsalva’s maneuver, awakens the patient from sleep, is newly onset in an older person, or is progressively worsening), the evidence is insufficient to make specific recommendations
In patients with a normal neurological examination if they have atypical features to their headache
An MRI is preferred to a CT scan for the above situations,
unless it is contraindicated or emergent
neuroimaging is needed.
Slide13Back to the tumor question…
0.0056% of children exhibiting a typical migraine or headache will have a tumor
56 children out of 100,000
(personal communication, Elizabeth Doll, MD, 2018)
Your examination and history taking skills are vital
Slide14Acute/ Abortive Treatment
Do not overlook the simple treatments requiring no Rx
Hydration
Sleep
Decrease stimulation
Dim lights
Medications
Non-steroidal anti-inflammatories
Triptans
Steroids
Over the counter combination therapies
Slide15Some Contraindications
1
. Last dose of a
triptan
within 2 hours
2. More than 2 doses of a
triptan
within a 24 hour period
3. Last dose of
triptan
within 24 hours prior DHE
4. Last dose of NSAID within 6 hours
5. Pregnancy
6. Breastfeeding
7. Angina
8. Ischemic heart disease
9. Perivascular disease
10. HTN
11. CAD
12. Concurrent MAO inhibitors or serotonin agonists
13. Concurrent potent 3A4 inhibitors
14. Concurrent peripheral and central vasoconstrictors
15. Hemiplegic or Basilar migraine
16. Severe hepatic and renal disease
Slide16NSAIDS
Naproxen > Ibuprofen > Acetaminophen
Naproxen
Approved for pain in ages >12
5 mg/kg or 500 mg PO initially, then 250 mg PO q6-8hr or
500 mg PO q12hr PRN;
not to exceed 1250 mg/day on day 1; subsequent daily doses should not exceed 1000 mg
NSAID precautions and contraindications
At least 6 hours between doses
GI caution
Bleeding caution
More efficacious if given with a
triptan
Slide17NSAIDS
Naproxen > Ibuprofen > Acetaminophen
Ibuprofen
10 mg/kg/dose every 6 hours
Not to exceed 600 mg/dose or 40 mg/kg/day
Approved for children > 6 months of age
NSAID precautions
Twice as efficacious as acetaminophen
Acetaminophen
15 mg/kg/dose max 1000mg every 4 hours
Max daily dose of 75 mg/kg or 4000 mg
Slide18NSAIDS
Age
Recommendation if no contraindications
Initial
Dose at onset of HA
> 12 years
Naproxen
5 mg/kg;
MAX 500mg at onset
6 months – 12 years
Ibuprofen
10 mg/kg; max 600mg
<6 months
Acetaminophen
15 mg/kg; max 1000mg
Slide19Triptans
Produce vasoconstriction
Best if used early
May repeat, x1, 2 hours after initial dose if migraine persists
Many contraindications, including, but not limited to:
Stoke
CV disease,
HTNPregnancyPay attention to ages
Slide20Triptans
(
Patniyot
, 2015)
Triptan
Age
Dose
Almotriptan
(
Axert
)
> 12 years
6.25 or 12.5 mg
Eletriptan
(
Relpax
)
> 12 years
40 mg
Rizatriptan
(
Maxalt
)
> 6 years
5 mg (<40 kg) to 10 mg
(>40kg)
Sumatriptan
(
Imitrex
)
> 12 years
> 18 years
*5 to 20 mg orally or 6 mg subcutaneously
5, 10, or 20 mg
intranasally
Zolmitriptan
(
Zomig
)
> 12 years
2.5 to 5 mg or 5 mg nasal spray
For young people aged 12–17 years
consider
a nasal
triptan
in preference to an oral
triptan
.
*lower doses were just as effective as higher doses with pain relief, but not associated symptoms
Slide21Triptans
(
Patniyot
, 2015)
Recommendation: At onset of headache, administer Naproxen
AND
Triptan
For older children, intranasal triptan
is preferred over oral
Always consider indications and contraindications of medications
Slide22Other Treatments
(Alfonzo & Chen, 2015) & (National Guideline Clearinghouse, 2012)
Sumatriptan
/Naproxen oral tablets (
Treximet
) 10/60mg up to 85/500mg; MAX x1 85/500mg tab/day
> 12 years of age
Nausea and vomiting: Ondansetron (Zofran) 0.1 mg/kg; MAX 8mg every 8 hours PRN
Dopamine Receptor Antagonists:
Promethazine (
Phernergan
): 0.25—1 mg/kg/dose; MAX 25 mg/dose
Metoclopramide: 0.1
–
0.2 mg/kg/dose; MAX 10mg
Consider diphenhydramine (
benadryl
)
DO NOT GIVE OPIOIDS
No research supports use of steroids
Abortive medications should not be used more than 2-3x/week or 10x/month
Mind and Body
Slide23Preventing Migraines
Find the trigger
(Lee, 2017):
Slide24When to prevent…
Consider:
Quality of life (QOL)
Degree of disability
HA characteristics: frequency, severity, duration
Generally,
1. If the patient has two (2) or more headaches per week that are associated with disability or
2. > 3 incapacitating headaches per month or
3. If the headache is predictable (ex. premenstrual migraine)
Prophylaxis takes up to 4-6 months to reduce HA frequency
Slide25Preventative treatments
Antidepressants
Antihypertensives
Antiepileptics
Antihistamines
Other
Slide26Antidepressants & Antihypertensives
(Hickman, Lewis, Little,
Rastogi
, &
Yonker
, 2015)
Antidepressants
Tricyclic Antidepressants (TCAs)Amitriptyline 0.25- 1 mg/kg/day; dose at bedtime; start low and increase to max of 75 mg/dayNortriptyline similar dosing to above; not as sedating
SSRIs more beneficial in adults than children
Antihypertensives
Beta Blockers: Propranolol 0.5-1 mg/kg/day divided BID (Initial MAX 80 mg/day) or Atenolol 0.5-1 mg/kg/day divided BID (Initial MAX 50 mg/day)
Calcium Channel Blockers: Verapamil 2-3 mg/kg/day divided BID (Initial MAX 240 mg/day)
BLACK BOX WARNING
Slide27Antiepileptics
Antieplieptics
Topiramate
–
approved in children >12 for migraine; 2-3 mg/kg/day; MAX 200mg/day
CAUTION in girls of child bearing age
Kidney stones, word finding difficultiesIncrease dose slowly
Valproic
Acid
–
used in adults for migraine prevention; 10-20 mg/kg/day; MAX 1000 mg
CAUTION in girls of child bearing age
Thrombocytopenia
Weight gain!
BLACK BOX WARNING
Slide28Antihistamines
Cyproheptadine
:
Used since the 1970’s in children to prevent headaches
Usually for younger children
0.2-0.4 mg/kg/day dosed at night
SEDATION
Appetite stimulant
Slide29Other Treatments
Botulinum toxin
Fluid
Drink at least 6 cups (1.5L) of water daily
Remover or reduce caffeine from the diet
Sleep
Maintain a regular sleep pattern every day
Diet and exercise
Eat 3 meals a day, do NOT skip meals
Eat a protein source for breakfast
Maintain a healthy body weight
Exercise for 30 minutes daily
Mind and body
Accupuncture
Biobehavior
techniques are beneficial
Relaxation training
Biofeedback
Cognitive behavior therapy
Stress management
Supplements
Magnesium Oxide 9 mg/kg/day BID (MAX 600 mg/day)
Coenzyme Q10 1-3 mg/kg/day daily (MAX 150 mg/day)
Vitamin B2 200-400 mg/day daily
Slide30When to refer
Abnormal brain imaging
Migraines with unusual neurological symptoms
Chronic migraines
15 or more headaches a month for three months or longer, often as a result of medication overuse
Intractable migraines
Migraines not helped by medications
Any headache outside the clinical criteria for migraine or tension-type headache There are more than 200 different types of headache disorders in the International Classification of Headache Disorders. Although migraines and tension-type headaches are most common, there are a myriad of other headache disorders.
Slide31But…
Do not be afraid to start approved or recommended treatments, both acute and preventative
…
It may take months for preventative medications to take effect!
Slide32Lee, K. H. (2017). Recent updates on treatment for pediatric migraine.
J Korean Med Association
. Feb;60(2):118-125.
https://doi.org/10.5124/jkma.2017.60.2.118
National Guideline Clearinghouse (NGC). Guideline summary: Headaches: diagnosis and management of headaches in young people and adults. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Sep 01. [cited 2018 Jan 20]. Available: https://
www.guideline.gov